Hospital Discharge: Best Practices for a Seamless Transition.

Abstract

This article describes best practices for hospital discharge transitions and reviews why health care teams should implement effective discharge planning strategies including interdisciplinary team collaboration, patient-centered education, and clear communication protocols. We review risk stratification tools for identifying patients at high readmission risk and evidence-based intervention bundles proven to reduce rehospitalizations. Implementation challenges including communication failures, caregiver engagement gaps, and resource constraints are addressed through implementation science approaches. Those aiming to improve the hospital discharge care transition should modify discharge processes to include community resource linkages and technology integration to achieve seamless transitions that improve patient safety and reduce rehospitalizations.